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Tuesday, December 5, 2017

Insertional Achilles Tendonitis Recovery

If you've been following this blog you'll know that I have been struggling with insertional Achilles Tendonitis for the past few months. I'm delighted to say (and I hope I am not speaking too soon) that I have made a near-full recovery, or at the least have experienced a dramatic improvement. I'm writing this blog primarily for my own records, and also in the hopes that it helps someone else out there. I am not a medical professional, but I thought I would share my experience and what helped me recover.

Onset
This all started in mid-July when I noticed stiffness on the backs of my heels when waking up in the morning and taking those first few steps. I didn't think it was a big deal at the time because it wasn't painful (stiffness is the best term for it) and I really only felt it when I first got out of bed. After a few weeks, the issue became more noticeable while on the Great Alaskan Running Cruise. It still wasn't painful, but I felt the stiffness more frequently, like after running.

At this point, I consulted with Dr. Google and diagnosed myself with Achilles tendonitis in both feet. What I didn't realize, though, is that there are two types of Achilles tendonitis: insertional and midpoint. The treatment for each of these is different. However, without knowing this fact (and that's the danger of Dr. Google) I started doing the exercises that had proven to heal midpoint tendonitis.

Progression
I did these exercises every day throughout the month of August. The exercise was standing on the edge of a step, and doing heel drops so that my heel fell below the step. This was slightly painful to do, but the article I read said that these exercises should feel painful. I also stretched my calves thoroughly each day.

The pain gradually worsened in that I would feel it after almost every run. My runs were completely pain-free (with maybe a hint of stiffness at the beginning), but then I would spend 40 minutes driving to work, which resulted in them stiffening up substantially. I would get out of my car and the first few steps would be really painful. The pain would last for the first hour of the day and then subside. This pattern continued for a month before I finally decided to see my sports chiropractor.

Rehab Exercises
My sports chiropractor told me that by stretching and doing those exercises, I was treating midpoint Achilles tendonitis, not insertional tendonitis. He told me that stretching my calves and sinking my heel below the step was putting additional strain on the tendon and making things worse! Oops! He told me that I should do eccentric heel drops on each foot, but on a flat surface. He told me that I should use as much weight as tolerated because the added weight would stimulate healing.

Ideally I would back off of the training, but given that I had a marathon approaching, he told me I could continue running, as long as I did the exercises every day. And once the marathon was over, he advised that I take a few weeks off to let the tendons completely recover.

I was very good about doing the exercises and I saw a notable improvement within just a few days. What a relief! I wore a backpack with 20 lbs worth of weights inside while I did the heel drops. I did 3 sets of 15 on each side, as prescribed, twice a day. As prescribed, I did these very slowly (lasting 3 seconds for the full drop) starting from half the height of full tippy-toes.

I continued training, running 60-70 miles a week, and sure enough, the pain worsened again a month later. Even though my actual runs were pain free, my heels really hurt afterwards. After a 22-miler, they hurt all day long, so I ended up taking 3 full days off from running. The most worrisome part about this was that my heels hurt when I was at rest, whereas typically they would only hurt when walking. The time off worked, with the pain diminishing significantly, and I was able to resume training, with just three weeks left to go.

The Smith Machine

I lower the bar and hold it in a relaxed position

The marathon came and went. My heels were mostly pain-free during the race, but they were extremely painful afterwards. With every step I took I could feel a burning sensation! I took two weeks off from running and spent this time focusing on recovery. After doing more research on insertional Achilles Tendonitis, I realized that my backpack-with-weights approach was not allowing me to add enough weight to stimulate tendon recovery. These exercises didn't hurt at all, and apparently they were supposed to hurt a little bit.

So, I discovered the Smith Machine at gym in my office building. This machine allows me to do the heel drops with a lot more weight, as it is easier to use the bar than wear a backpack. I simply hold the bar with my arms in a relaxed position down at my thighs. I started off with 25 lbs + the weight of the bar and after about a week, upped it to 30 lbs + the weight of the bar. I started doing the exercises twice a day, 15 reps on each side. And I am still doing them at this level.

Doing the heel drops with this machine has helped me more than anything. As soon as I discovered it, my Achilles felt dramatically better within just two days. I've now been using this machine for three weeks, and I am close to 100% recovered. By that I mean that most days are completely pain free, and on the days I do feel it, it's only for a minute at a time, like once or twice during the day. This injury developed gradually so I imagine it will take awhile to become 100% pain free 100% of the time. But I am very close to being there.

FAQ
Here are some questions I had about this injury, and the answers I discovered. Once again, I am not a medical professional so take this as one runner's experience and opinion!

Shoes I wear to avoid additional tendon strain

Q: What type of shoes should I wear when not running?
A: My sports chiropractor advised me to wear a backless shoe with a chunky 1-2 inch heel, and that the heel height would relieve the strain on the tendon. While high heels are not a good long-term solution, they did allow me to be pain-free while walking around, and in order to recover fully, it's necessary to reduce strain on the tendon as much as possible.

Q: How do I know how much weight to use for the heel drops?
A: I started with a low weight (15 lbs in the backpack) and worked my way up. I think it's supposed to slightly hurt in the area of pain, but not horribly so. All of the articles I've read say "once you can do this without pain, then up the weight." So I assume there should be a little bit of pain or you aren't using a heavy enough weight. I saw the most improvement when I discovered the Smith machine and used 25 lbs plus the weight of the bar.

Q: How do I know if I should run?
A: This is a tough question, especially if you are pain-free while running. I think it really depends on how bad the situation is, and you should consult a medical professional. When my Achilles started to ache all the time (even when not walking) I knew it was time to stop running altogether until they calmed down. Recovery is not linear-- some days are better and some days are worse. It's important to look for a trend towards improvement and if you aren't seeing that, then it means you should reduce your mileage or stop running.

Q: What causes insertional Achilles tendonitis?A: In my case, I think it was a change in footwear. I had been using a 10mm drop firm shoe for my speed work for the past decade, and then I changed to an 8mm drop cushy shoe in June. Even though this is only 2mm difference, my heel was getting even closer to the ground because of the cushiness of the shoe. My sports chiropractor cautioned me that those heel drop numbers can be deceiving because you have to take into account how stiff/firm the shoe is. I have limited ankle mobility, so I am not a candidate for a low heel drop shoe. Generally speaking, a high heel-to-toe ratio is best for preventing Achilles tendonitis.

Q: Should I ice or heat the tendon?
A: I've gotten conflicting guidance on this from multiple trusted sources. I tried icing my heels once after a run and 5 minutes in, they started burning really badly. So I nixed ice. Tendonitis means that the tendon is inflamed, so heat isn't a great idea either. However, heating the lower calf to get blood flow to the area is a good idea before runs.

Q: What's the best form of cross training?

Getting ready to go deep water running!

A: I was reluctant to use the elliptical machine or the bike because those machines can place strain on the tendon by forcing the foot to flex upwards. Swimming and pool running were a good option for me because I don't move my feet much when I do those activities. A more skilled swimmer might potentially move his/her feet more and thus irritate the tendon. I am not all that skilled!

Q: What about a night splint?
A: My podiatrist gave me a night boot/splint thing to wear while sleeping, but my sports chiropractor thought this was a bad idea. What to do? Since the boot didn't fit me anyway, I never used it, but I know some people have had relief with it. It basically keeps your foot in a neutral position overnight (not allowing the tendon to shorten/relax) so that when you get up and start walking around, your tendon has adjusted to being lengthened.

Q: Can the tendon rupture?
A: My sports chiro and my podiatrist both told me that this would not happen from long distance running. A rupture occurs from sudden force, which is more likely to happen in soccer or basketball. I ran a marathon with insertional Achilles tendonitis and it didn't rupture.

My best advice to anyone struggling with insertional Achilles tendonitis is to see a doctor, PT, or sports chiropractor. It's important to have a correct diagnosis and to pinpoint what caused the issue. It's also important to have a medical professional watch you do the exercises so that you know you are doing them correctly.

21 comments:

I haven't had this injury (knock on wood), but really like how you did this blog post to address it. I've had every other tendonitis it seems (peroneal, hamstring), and when I am injured, I always look for blog posts about it just because it's neat to have someone to bounce ideas off of or see what worked for other people. Of course everyone's injury experience is different, and no blog post is a substitute for seeing a doctor, PT, etc- but it's nice to read it from someone on your level and not feel so alone.

Can you explain how you performed your smith machine exercises..(specifically, how did you get into your starting position without doing a calf raise first?) Thank you....and glad to hear you made a great recovery...I'm hoping for the same results.

I started with both feet flat on the floor, no shoes. I raised both heels until I was halfway up to my tippy toes. Then, I lifted one foot off the ground, and did the lowering using the other foot. I then put the other foot back on the ground, raised both feet up to halfway, and then came down on one foot only. I hope that makes sense!

This sounds exactly like what I've been going through and I've really struggled with it. I was running around 80 miles a week consistently and all of a sudden I had pain in my heel which I originally thought was just a blister and ignored it for about a week until I couldn't run any further.

The pain was bad and after some research I just decided to have a good bit of time off to recover from it (8 weeks). I've tried absolutely everything, heel raises, ice, heat, physio, stretching, heel lifts in shoes etc.

8 weeks later, I was pain free walking and was sick so I decided to start jogging again. I was happy with how I felt and managed 3 weeks upping the running to around 30 miles per week where I'm at now. However, I've just started to feel a burning sensation again in the heel area so I'm worried it's flared up again.

There is zero pain when I run or walk but when I sit around I'm well aware of it tingling. When you came back to running were you aware of it for a while or should I back off?

I can do the heel raises with no pain but when I do them off the step it still hurts and I still can't stretch the achilles as it feels like its tearing. I've never really had any swelling.

Sorry for the long post but this is the first time I've came across that someone has the same issue as me.

Sorry you are going through this. I'm not 100% sure you have exactly what I had, but it is possible. For me, recovery was not linear. It wasn't like it suddenly vanished one day, never to return. I just had fewer and fewer days of it hurting, and more and more days where I was pain free. I think the key is to make sure you are using enough weight when you are lowering your heels to the ground. There is no need to do it off of a step; flat ground is perfect as you don't want your heel dropping lower than your forefoot. I hope this helps!

Just a couple questions:How do you deal with your tight calves after running if you can't stretch them? I have insertional achilles tendonitis as well and stretching does aggravate it, but now i have very tight calves.

And secondly, just to confirm, are you doing three sets of 15 on each leg, twice per day, on the smith machine?

Hi Nick. I use the stick to massage my calves or ask my husband to massage them. I find that massage is more effective for loosening muscles as opposed to stretching. Yes. The protocol I was given was three sets of 15 on each leg, twice per day. As I started to improve I decreased it to once per day.

Hi Nick. I use the stick to massage my calves or ask my husband to massage them. I find that massage is more effective for loosening muscles as opposed to stretching. Yes. The protocol I was given was three sets of 15 on each leg, twice per day. As I started to improve I decreased it to once per day.

Hi! I just came across your post and I’ve actially been a follower of yours on Instagram! I ran Boston in April and after both achilles were extremely sore. My right one seemed to heal quickly but the left one ended up having a bump right on the heel (at the insertion where the heel connects to the achilles). I’ve been struggling getting back to consistent running, it’s been really hard. I was wondering if you also had a bump on the back of your heel and if the exercises helped decrease it in size along with the associated pain?

Hi Rachel. I suggest doing a Google search for "Haglund's Deformity" and seeing if that's what you have. I always have a bump there, but it became more noticeable with the tendonitis. After doing these weighted heal drops, the bump got smaller and became less painful. I'm not sure if this is what you have, but worth considering!

Very informative post. Ive had similar problems with insertional achilles pain, Its back and fourth between my feet every 3 to 4 months and i get lots of morning stiffness.Question:How did you alleviate your morning calf stiffness and the stiffness that occurs after sitting for periods of time? When this occurs i know something isnt right and i dont even run or play sports. Anything that worked for you or you suggest?

Bob, get shockwave therapy from a physio or podiatrist - also when doing the heel drops you need to go heavier and heavier - your Achilles should be able to take 1.5x your body weight. Obviously don't try that at the start instead build up to that. Try 3 sessions per week with smith machine 3x6-8 reps. Shockwave has proven results for many who have chronic IAT. FYI I'm not a professional but I've learned the above and put it in to practice to good effect from professionals (podiatrists and physics). Good luck

Great write-up for rehab, and thank you for sharing your experience! Been dealing with this for a while, and wearing a heel lift helps reduce much of the day-to-day strain. I'll be trying to do more of the modified eccentric heel drops, thank you!

I did the isometric heel raises w/o much relief. I realized later my homemade orthotic had the affected limb 1/3 inch higher. I corrected that. After about 5 months I went from 200 gm daily protein to 350 gm with bulk foods whey isolate included and pain went from a 8 to a 1/10 post run. I had read as well that the calf start h was counterproductive but I'm not sure that's correct ie as it seemed to relieve the pain. I can't prove it but feel the 350 gm protein a day from 200 gm was the clincher.